87R16947 RDS-F
 
  By: Bonnen H.B. No. 3459
 
  Substitute the following for H.B. No. 3459:
 
  By:  Oliverson C.S.H.B. No. 3459
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to preauthorization requirements for certain medical and
  health care services and utilization review for certain health
  benefit plans.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Subchapter J, Chapter 843, Insurance Code, is
  amended by adding Section 843.3484 to read as follows:
         Sec. 843.3484.  EXEMPTION FROM PREAUTHORIZATION
  REQUIREMENTS FOR PHYSICIANS AND PROVIDERS PROVIDING CERTAIN HEALTH
  CARE SERVICES. (a) A health maintenance organization that uses a
  preauthorization process for health care services may not require a
  physician or provider to obtain preauthorization for a particular
  health care service if, in the preceding calendar year:
               (1)  the physician or provider submitted not less than
  five preauthorization requests for the particular health care
  service; and
               (2)  the health maintenance organization approved not
  less than 80 percent of the preauthorization requests submitted by
  the physician or provider for the particular health care service.
         (b)  An exemption from preauthorization requirements under
  Subsection (a) lasts for one calendar year. 
         (c)  Not later than January 30 of each calendar year, a
  health maintenance organization must provide to a physician or
  provider who qualifies for an exemption from preauthorization
  requirements under Subsection (a) a notice that includes:
               (1)  a statement that the physician or provider
  qualifies for an exemption from preauthorization requirements
  under Subsection (a);
               (2)  a list of the health care services to which the
  exemption applies; and
               (3)  a statement that the exemption applies only for
  the calendar year in which the physician or provider receives the
  notice.
         (d)  If a physician or provider submits a preauthorization
  request for a health care service for which the physician or
  provider qualifies for an exemption from preauthorization
  requirements under Subsection (a), the health maintenance
  organization must promptly provide a notice to the physician or
  provider that includes:
               (1)  the information described by Subsection (c); and
               (2)  a notification of the health maintenance
  organization payment requirements described by Subsection (e).
         (e)  A health maintenance organization may not deny or reduce
  payment to a physician or provider for a health care service to
  which the physician or provider qualifies for an exemption from
  preauthorization requirements under Subsection (a) based on
  medical necessity or appropriateness of care. 
         SECTION 2.  Subchapter C-1, Chapter 1301, Insurance Code, is
  amended by adding Section 1301.1354 to read as follows:
         Sec. 1301.1354.  EXEMPTION FROM PREAUTHORIZATION
  REQUIREMENTS FOR PHYSICIANS AND HEALTH CARE PROVIDERS PROVIDING
  CERTAIN HEALTH CARE SERVICES. (a) An insurer that uses a
  preauthorization process for medical care or health care services
  may not require a physician or health care provider to obtain
  preauthorization for a particular medical or health care service
  if, in the preceding calendar year:
               (1)  the physician or health care provider submitted
  not less than five preauthorization requests for the particular
  medical or health care service; and
               (2)  the insurer approved not less than 80 percent of
  the preauthorization requests submitted by the physician or health
  care provider for the particular medical or health care service.
         (b)  An exemption from preauthorization requirements under
  Subsection (a) lasts for one calendar year.
         (c)  Not later than January 30 of each calendar year, an
  insurer must provide to a physician or health care provider who
  qualifies for an exemption from preauthorization requirements
  under Subsection (a) a notice that includes:
               (1)  a statement that the physician or health care
  provider qualifies for an exemption from preauthorization
  requirements under Subsection (a);
               (2)  a list of the medical or health care services to
  which the exemption applies; and
               (3)  a statement that the exemption applies only for
  the calendar year in which the physician or health care provider
  receives the notice.
         (d)  If a physician or health care provider submits a
  preauthorization request for a medical or health care service for
  which the physician or health care provider qualifies for an
  exemption from preauthorization requirements under Subsection (a),
  the insurer must promptly provide a notice to the physician or
  health care provider that includes:
               (1)  the information described by Subsection (c); and
               (2)  a notification of the insurer payment requirements
  described by Subsection (e).
         (e)  An insurer may not deny or reduce payment to a physician
  or health care provider for a medical or health care service to
  which the physician or health care provider qualifies for an
  exemption from preauthorization requirements under Subsection (a)
  based on medical necessity or appropriateness of care. 
         SECTION 3.  Section 4201.206, Insurance Code, is amended to
  read as follows:
         Sec. 4201.206.  OPPORTUNITY TO DISCUSS TREATMENT BEFORE
  ADVERSE DETERMINATION. (a) Subject to Subsection (b) and the
  notice requirements of Subchapter G, before an adverse
  determination is issued by a utilization review agent who questions
  the medical necessity, the appropriateness, or the experimental or
  investigational nature of a health care service, the agent shall
  provide the health care provider who ordered, requested, provided,
  or is to provide the service a reasonable opportunity to discuss
  with a physician licensed to practice medicine in this state the
  patient's treatment plan and the clinical basis for the agent's
  determination.
         (b)  If the health care service described by Subsection (a)
  was ordered, requested, or provided, or is to be provided by a
  physician, the opportunity described by that subsection must be
  with a physician licensed to practice medicine in this state and who
  has the same or similar specialty as the physician.
         SECTION 4.  The changes in law made by this Act to Chapters
  843 and 1301, Insurance Code, apply only to a request for
  preauthorization of medical care or health care services made on or
  after January 1, 2022. A request for preauthorization of medical
  care or health care services made before January 1, 2022, is
  governed by the law as it existed immediately before the effective
  date of this Act, and that law is continued in effect for that
  purpose.
         SECTION 5.  Section 4201.206, Insurance Code, as amended by
  this Act, applies only to a utilization review requested on or after
  the effective date of this Act. A utilization review requested
  before the effective date of this Act is governed by the law as it
  existed immediately before the effective date of this Act, and that
  law is continued in effect for that purpose.
         SECTION 6.  This Act takes effect September 1, 2021.